HIV, HAART, and the Kidneys

Jeffrey Laurence, M.D.

November 17, 2009—Mild kidney disease is seen in up to one-third of HIV-positive individuals. But the prevalence of more significant chronic kidney disease, with associated morbidity and premature death, is expected to increase as the HIV-positive population ages. Writing in the October issue of AIDS, amfAR grantee Dr. Steven Deeks and his colleagues at the University of California, San Francisco, reported on the relationships between HIV, highly active antiretroviral treatment (HAART), and the risk of developing kidney disease.

Dr. Deeks and his colleagues assessed the kidney function of HIV-positive people by tracking changes in a blood-borne protein known as creatinine. Compared with HIV-positive patients who were not on anti-HIV drugs, those initiating HAART found that the treatment slowed the estimated loss of kidney function. But loss of function continued nonetheless, and accelerated in patients on HAART who experienced intermittent rises in viral load, or viral “blips.”

This study, part of an ongoing trial known as SCOPE—Study of the Consequences of the Protease Inhibitor Era—has important implications for how to mitigate the risk of kidney disease among those living with HIV. Dr. Deeks and colleagues concluded that HAART is beneficial to kidney function, but that close monitoring of viral load and medication adherence in order to curb episodic viral blips may be critical to maintaining that function. They also found that doctors should be especially vigilant in identifying traditional risk factors for kidney disease, such as diabetes and high blood pressure, which are important risk factors for kidney function decline in HIV-positive people and may be complicated in these patients by the virus or its treatment.

The study also highlighted concerns that patients requiring HAART to maintain viral control had much higher rates of kidney function decline compared to elite controllers—people whose viral loads remain undetectable even without treatment. Dr. Deeks and his associates concluded that “factors related to race, underlying kidney disease, immune status, or viral replication may interact with ART to produce contrasting effects. Clinicians will need to counsel patients on the risk of kidney disease with long-term therapy.”

Earlier this year, Dr. Deeks and his colleagues reported parallel findings with respect to heart disease, writing in the June issue of AIDS that cardiac risk was strongly associated with HIV infection regardless of the patient’s viral load or whether the patient was on HAART.